Chest pain in the emergency department: risk stratification with Manchester triage system and HEART score

Luís Leite, Rui Baptista, Jorge Leitão, Joana Cochicho, Filipe Breda, Luís Elvas, Isabel Fonseca, Armando Carvalho, José Nascimento Costa, Luís Leite, Rui Baptista, Jorge Leitão, Joana Cochicho, Filipe Breda, Luís Elvas, Isabel Fonseca, Armando Carvalho, José Nascimento Costa

Abstract

Background: Fast and accurate chest pain risk stratification in the emergency department (ED) is critical. The HEART score predicts the short-term incidence of major adverse cardiac events (MACE) in this population, dividing it in three risk categories. We aimed to describe the population with chest pain, to characterize the subgroup of patients with acute coronary syndrome (ACS) and to assess the prognostic value of Manchester triage system and of HEART score.

Methods: Retrospective observational study including patients admitted to the ED of a tertiary hospital with chest pain as the presenting symptom. The primary outcome was a composite of all-cause mortality, myocardial infarction or unscheduled revascularization at 6 weeks.

Results: We enrolled 233 patients (age 58 ± 19; 55.4 % males). The most common final diagnosis was non-specific chest pain (n = 86, 36.9 %), followed by ACS (n = 22, 9.4 %). Male gender, smoking and chronic kidney disease were associated with higher risk of ACS. According to Manchester triage system, chest pain patients stratified with red or orange priority had a higher incidence of ACS (16.5 % vs. 3.8 %, p = 0.006). The application of HEART score showed that most patients were in low risk category (56.3 %). The six-week incidence of MACE in each category was 2 %, 15.6 % and 76.9 % (p < 0.001). HEART score accurately predicted the short-term incidence of MACE in chest pain patients (c-statistic 0.880; 95 % CI, 0.807-0.950, p < 0.001).

Conclusions: Chest pain patients have very different levels of severity and the discriminatory power of Manchester triage system should be used in the assessment of this population. The HEART score seems to be an effective tool for risk stratification in the ED.

Figures

Figure 1
Figure 1
Final diagnosis of patients. COPD, chronic obstructive pulmonary disease
Figure 2
Figure 2
Flow diagram of patients presenting with chest pain. ED, emergency department; ACS, acute coronary syndrome; MACE, major adverse cardiovascular events
Figure 3
Figure 3
Incidence of 6-week MACE in each HEART score. MACE, major adverse cardiovascular events
Figure 4
Figure 4
Incidence 6-week MACE in each HEART score risk category. MACE, major adverse cardiovascular events

References

    1. Fernández JB, Ezquerra EA, Genover XB, O’Callaghan AC, Gárriz I, Nácher J, Torres FM, Romero SG. Chest pain units. Organization and protocol for the diagnosis of acute coronary syndromes. Rev Esp Cardiol. 2002;55:143–54. doi: 10.1016/S0300-8932(02)76574-3.
    1. Pitts SR, Niska RW, Xu J, Burt CW. National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary. Natl Health Stat Report. 2008;7:1–38.
    1. Cooke MW, Jinks S. Does the Manchester triage system detect the critically ill? J Accid Emerg Med. 1999;16:179–81. doi: 10.1136/emj.16.3.179.
    1. Backus BE, Six AJ, Kelder JC, Mast TP, van den Akker F, Gijis Mast EG, Monnink SHJ, van Tooren RM, Doevendans PAFM. Chest pain in the emergency room: a multicenter validation of the HEART Score. Crit Pathw Cardiol. 2010;9:164–9. doi: 10.1097/HPC.0b013e3181ec36d8.
    1. Hamm CW, Bassand J-P, Agewall S, Bax J, Boersma E, Bueno H, Caso P, Dudek D, Gielen S, Huber K, Ohman M, Petrie MC, Sonntag F, Uva MS, Storey RF, Wijns W, Zahger D. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation. Eur Heart J. 2011;32:2999–3054. doi: 10.1093/eurheartj/ehr236.
    1. Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Neth Heart J. 2008;16:191–6. doi: 10.1007/BF03086144.
    1. Martínez-Sellés M, Bueno H, Sacristán A, Estévez A, Ortiz J, Gallego L, Fernández-Avilés F. Chest pain in the emergency department: incidence, clinical characteristics and risk stratification. Rev Esp Cardiol. 2008;61:953–9. doi: 10.1157/13125517.
    1. Burman RA, Zakariassen E, Hunskaar S. Acute chest pain - a prospective population based study of contacts to Norwegian emergency medical communication centres. BMC Emerg Med. 2011;11:9. doi: 10.1186/1471-227X-11-9.
    1. Hess EP, Perry JJ, Calder LA, Thiruganasambandamoorthy V, Roger VL, Wells GA, Stiell IG. Sex differences in clinical presentation, management and outcome in emergency department patients with chest pain. CJEM. 2010;12:405–13.
    1. Erhardt L, Herlitz J, Bossaert L, Halinen M, Keltai M, Koster R, Marcassa C, Quinn T, van Weert H. Task force on the management of chest pain. Eur Heart J. 2002;23:1153–76. doi: 10.1053/euhj.2002.3194.
    1. Groarke J, O’Brien J, Go G, Susanto M, Owens P, Maree AO. Cost burden of non-specific chest pain admissions. Ir J Med Sci. 2013;182(1):57–61. doi: 10.1007/s11845-012-0826-5.
    1. Perk J, De Backer G, Gohlke H, Graham I, Reiner Z, Verschuren M, Albus C, Benlian P, Boysen G, Cifkova R, Deaton C, Ebrahim S, Fisher M, Germano G, Hobbs R, Hoes A, Karadeniz S, Mezzani A, Prescott E, Ryden L, Scherer M, Syvänne M, Scholte op Reimer WJM, Vrints C, Wood D, Zamorano JL, Zannad F. European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice. Eur Heart J. 2012;2012(33):1635–701.
    1. Pinto D, Lunet N, Azevedo A. Sensitivity and specificity of the Manchester Triage System for patients with acute coronary syndrome. Rev Port Cardiol. 2010;29:961–87.
    1. Providência R, Gomes PL, Barra S, Silva J, Seca L, Antunes A, Pais JR, Mota P, Leitão-Marques A. Importance of Manchester Triage in acute myocardial infarction: impact on prognosis. Emerg Med J. 2011;28:212–6. doi: 10.1136/emj.2009.081497.
    1. Backus BE, Six AJ, Kelder JH, Gibler WB, Moll FL, Doevendans PA. Risk scores for patients with chest pain: evaluation in the emergency department. Curr Cardiol Rev. 2011;7:2–8. doi: 10.2174/157340311795677662.

Source: PubMed

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